C.A.R.E.

Five years ago, the Office of the Inspector General received a difficult report stating that one in three residents admitted to a skilled nursing facility experienced an adverse event resulting in harm within the first 35 days of their stay. The report estimated that 60% of such events were preventable. The IMPACT Act of 2014, and subsequent changes in the Requirements of Participation for Skilled Nursing Facilities are results of this monumental and eye-opening report.

Phase III of the IMPACT Act of 2014 goes into effect November 28, 2019. Key changes within Phase III are related to QAPI requirements and advance QAPI from a plan to a fully operational system of ongoing organizational learning and improvement. The combination of the new requirements with existing concerns listing QAPI as one of the top 10 F-Tags received by organizations during licensure surveys in 2018 results in a strong impetus to spotlight QAPI.

Given the emphasis on QAPI, what can the Skilled Nursing Facility expect? A good perspective is to make Quality Assurance/Performance improvement as a way of doing business. There are a myriad of metrics and initiatives on which leaders are focused. Do all of them require a full QAPI approach? Yes, but in a prioritized manner.

Focusing on the Vital Few initiatives will assure that progress is made in key high priority areas. A suggested approach is to focus on 4-5 key initiatives, inclusive of at least one initiative in resident rights, one in clinical effectiveness and one in work environment. Once the Vital Few initiatives have been identified, they should be posted transparently throughout the organization.

As an example, the QAA committee of Harmony Valley Nursing Center identified 25 opportunities for improvement. Of these, they used a prioritization process to select four key initiatives for their QAPI program:

reducing resident falls;

increasing resident satisfaction;

decreasing turnover of nursing assistants;

reducing use of antianxiety/hypnotic medications.

A charter was developed for each of the priority areas, and a Performance Improvement Project team leader was assigned. The PIPs were announced through the facility newsletter and volunteers were solicited for each of the four teams.

Each team used the Plan-Do-Study-Act (PDSA) system for performance improvement to implement rapid cycles of change.

Goals were established using a BHAG (big, hairy, audacious goal) approach. Updates on the PIPs were displayed on storyboards in the facility.

Results of each initiative were discussed quarterly at the QAA committee and progress made was celebrated by the organization during the annual employee recognition dinner.

As one dynamic healthcare leader once remarked, “If you are going to be naked, you need to be buff!”

In the Post-Acute environment, one might argue that we are indeed naked. Information regarding resident safety, satisfaction and quality of care are readily available with a few key strokes of any computer or smart phone. QAPI offers organizations a way of assuring that they are as buff as possible!